One of the things you don't think about, regarding outreach medicine, until you're in it: there's a lot of mindless scut work. Once the DASV/SOMOS team arrives in Santo Domingo, the most pressing task is to unpack, count, and package the thousands of pills that we bring with us. This year the meds from the US only included vitamins (adult and child) and antihistamines. Everything else had been ordered in-country in blister packs, tubes, or ready-to-reconsistute bottles. For hours, the main sounds in DASV HQ are the scratch of pill-counting spatulas, the clicking of pills against each other as they rush from the chute, the rustle of filled ziplocks piling up and being stashed in bigger plastic bags. The hush is occasionally broken by a burst of hilarity or editorial comments on the flavor and texture of pediatric vitamins. The pace builds as everyone gets into the grove, then slows as boredom sets in, then builds again as we open the final bottles; will we finish on time to celebrate the new year?

(Compared to last year's HQ - a normal room crammed full with a queen-sized bed, a cot, and three students' duffels - this year's room was posh. Dr. Mark's single turned out to be a bridal suite, with two love seats, a coffee table, and all the floor space we could wish for. This also meant that Mark's sweet bed-in-an-alcove remained relatively unmolested by sweaty, dirty crewmates perching on it during meetings.)

Mark is often heard to remark on how everybody helps out on these trips. Past president of William and Mary Gene Nichol even found himself wearing scrubs and working in the pharmacy on previous years' trips. I've never heard anybody balk or complain. There is no "your job" and "my job." There is just the work in front of us, and many hands available to do it.

The work done, it's time to head to the Plaza for rum and coke, purchased from a colmado along the way. Tomorrow morning will come soon, along with more work. We will face it together.

Back home and getting my head around all there is to say about the community in Esfuerzo and this year's SOMOS/DASV efforts. Right now, I'm catching up on sleep and snuggles (both were in short supply for me in the DR) and appreciating many things about my normal life, as well as many things about the 1/52nd of a year I spend outside of my normal life.

:: I'm grateful for fresh, clean vegetables. I'm grateful that even if I don't wash my grocery-store veggies, it's unlikely that I'll catch a bacterial or parasitic illness. I'm grateful for the luxury of worrying about pesticides and BPA.

:: I'm grateful that my trash is taken away from my house weekly by a big truck, and that I don't have to think about it at all. I'm grateful that my government maintains our community's infrastructure (roads, sanitation systems) well enough to keep this running smoothly.

:: I'm grateful for cool, sweet, healthy water that I can drink straight from the tap. I'm grateful for toilets that flush reliably.

:: I'm grateful that my period decided to wait until 40 minutes after I returned home to start, so that I didn't have to deal with it without reliably flushing toilets and clean water for washing hands. (I know this is TMI to some people, but y'all will have to get over it. Women menstruate and management of menstrual flow is a very real issue for women in developing countries.)

:: I'm grateful for relatively unpolluted air, and for emissions standards that prevent unlimited diesel exhaust from clogging the airways of the people in my country. I'm grateful for albuterol and antihistamines.

:: I'm grateful for the hospitality of strangers and the exuberance of children.

:: I'm grateful for being shown some of the universal things in life.

:: I'm grateful for a sense of adventure and the human mind's ability to soak in new languages and new customs.

:: I'm grateful for pharmacies that always have antibiotics, anxiolytics, cold remedies, blood pressure medication, and so many other things in stock. I'm grateful that all I have to do is go to the store, and I can be certain I can get what I need, when I need it. I'm grateful that these things are in such ready supply that I can keep stock in my home so that it's ready at a moment's notice.

:: I'm grateful for techology that fosters and supports connections between people via GPS, telecommunication, digital imagery, and so much more.

:: I'm grateful for the ability to document life via photography, and for the many ways in which my ability enables me to connect with people.

:: I'm grateful for a community of friends, both new and old, who find great fulfillment in digging deep into weighty topics, and who can also be completely silly.

All these things and more are in my heart and mind today. Thank you, my friends here in the States, and also to those of you in Paraíso. I am grateful for you.

¡Feliz Año Nuevo! The dawn of the new year found me waking up in Santo Domingo, having returned to the Dominican Republic to serve again as the documentary photographer for the Dominican Aid Society (DASV) and William and Mary’s Student Organization for Medical Outreach and Sustainability (SOMOS). While I spent a lot of time specifically thinking about and preparing for last year’s visit, this past fall barreled by, and in a wave of photography clients, family birthdays, school activities, and holiday preparations, the eve of the trip was upon me before I really had time to think about packing, much less review any Spanish (so much for studying all year) or form a game plan for this year’s documentation.

In the weeks leading up to this trip, several people asked me what my goals are, now that I have a better understanding of SOMOS and the DASV, the places where they work, and the people with whom they do that work. My answer was rarely more specific than “be more focused.” Be more focused on what? I’m only partly sure. Regarding the specific public health issues in Paraíso/Esfuerzo, I would like to spend more time thinking about waste management and potable water. Regarding the organization as a whole, I’m interested in the ways in which we communicate amongst ourselves and the ways in which we interact with the residents of Esfuerzo – by which I mean the communication styles employed and approaches to interpersonal relationships, rather than literal modes of communication. And of course, I continue to talk to my compatriots about the ethical issues we encounter as (mostly-white, mostly-affluent) citizens of a “first-world” country visiting a marginalized community in a developing (formerly referred to as “second-world”) nation.

Perhaps my largest goal for this trip is to challenge DASV/SOMOS to think about how they communicate their experiences and intentions to our communities at home in the United States. My questions for my fellow teammates would include:

What information do we want people in our home communities (local/regional/national) to know about DASV/SOMOS?

What do we want/need to receive from our home communities (discussion, monetary support, participation, etc)? How do we recruit these things?

What role does photographic documentation of our work play in this communication?

How can photographs help to illustrate our thoughts and experiences?

What types of images do we need?

While the group as a whole probably gives the most thought to communicating with our own communities in the months leading up to our visits and the months following it, and their attention is focused on the work at hand during the visits themselves, the nature of my work requires that I be thinking about what and how to communicate something just before and while it is happening. My continued participation in future DASV trips will depend largely upon how these questions are answered. Does the team need a documentary photographer every year, or only once or twice a decade? It should come as no surprise to you to learn that as a documentarian, I think there can be a role for myself or another photographer in every visit. The question is, what does the team perceive as their needs, and how can I best fill those needs?

Chances are that when it comes to clean drinking water, you are quite literally swimming in it. Most of us have such easy access to clean, healthy water that we can fill swimming pools with it, water our houseplants, take a bath whenever we want, leave the tap running while brushing our teeth, wash our clothes in it, heat our homes with it, use it for ice, entertain ourselves with it, play sports with it, relax to the sound of it running over decorative fountains, cook with as much of it as we like, and dump it down the drain if it doesn't taste fresh enough or cold enough for our liking.

What if you couldn't do this? What if you had no plumbing, or you did but couldn't trust the healthfulness of the water coming through the pipes? What if your choices were to drink unhealthy water, or buy expensive clean water?

Some of the homes in 28, 6, and Altos have running water, but if my observations at the school are any indication, plumbing works only intermittently. During our clinic week at the school, the water was turned off. We flushed toilets using buckets of water brought up from a rainwater cistern. We drank what we brought in bottles or purchased at a colmado, and refilled when necessary from a cooler holding clean water. Cleaning hands was done with hand sanitizer or by sacrificing a few precious drops of drinking water. I did this on occasion when my hands had gotten too grimy for sanitizer alone. It felt wasteful, because water was limited and clean hands seemed less important than hydration. When options are limited, your priorities become much more clear.

I previously mentioned the drainage ditches that flow from 28, 6, and Altos and curve around the West side of Esfuerzo.

These are full of runoff from the other neighborhoods - soap, garbage, silt, remnants of whatever has been scrubbed from floors, water that has seeped through burned trash, and potentially human waste as well.

Near Esfuerzo, runoff from the community joins the ditch. Keep in mind that there is no plumbing in any home in Esfuerzo. While some homes have pit toilets, others use containers, which must be emptied. Where are they being emptied? Your guess is as good as mine.

There is animal waste to be considered, as well. Pigs, horses, cattle, chickens, dogs, and cats roam this area.

The water in this ditch either sits stagnant (providing an ideal breeding place for mosquitoes carrying dengue or malaria), or flows into the river, where children play:

After Abel (on the right) showed me his flipping and diving skills, he refreshed himself with a drink from the river. I cringed and looked down at the bank next to me:

The adults - and, most likely, most of the kids - understand that drinking the water in the river is unhealthy. And in this particular situation, most kids would drink from the river (have you ever tried to prevent a kid from playing in or drinking from a river or lake?). The alternative, however, is to purchase water. Several homes in Esfuerzo run mini-colmados (corner stores). This one advertises "bags of water for sale."

I often saw empty baggies in the streets. I would estimate that each fundita holds about 8 ounces of water when full. You tear a corner to drink.

Imagine that your funds are already short, and if you want a drink of safe water, you have to pay for it, and then you receive it in a container which can easily be torn and cannot be re-capped, allowing you to save some for later? Consider that many of the households in Esfuerzo have a single, female head of household, and that she may be doing domestic work, for which she gets paid $100-125 USD per month, before she considers expenses such as travel to and from her job (which might include riding a gua-gua, or hiring a motoconcho, then taking the Metro, then a taxi). Clean water, which is considered by the UN to be a human right, may not be affordable and accessible enough to support good health.

Also imagine: if you didn't have plumbing and clean water were expensive, how would you bathe? Would you be likely to wash your hands before eating? A 2010 thesis shows that 60.2% of Dominican households do not treat their drinking water, and 59.8% of adults report diarrheal illness consistent with soil- and water-borne parasitic infections. SOMOS research indicates an overall parasitic infection rate of 48% of all people living in the developing world, with 10% infection by two or more organisms. In the Dominican Republic, approximately 20% of individuals are infected with roundworms; ~34% have amoebiasis, ~59% carry whipworm, and ~59% have hookworm infections. If one were to examine only members of communities without running water, I imagine the rates would be even higher.

The lack of clean water is related to infection with both water-borne and soil-borne parasites. The water is neither safe to drink, clean enough for bathing, nor available enough for the frequent washing required to defend against parasites in soil or fecal-oral contamination.

For a person who wishes to get medical treatment, there are many barriers. Finding time away from a job, paying for transportation to medical facilities, and arranging for time/transportation to a farmacia all reduce access to medical care. For a person who manages to get to a clinic, wait times may be prohibitively long. Once at a pharmacy, drugs might not be available, or if they are, they might be too expensive.

One of the most frequently-prescribed medications in the clinic is Albendazole. Every child who comes to the clinic receives it. Albendazole is easily obtained by an American physician and is inexpensive, approximately $0.02-0.03 (2-3 cents) per dose. It is effective against hookworms (soil), roundworms (fecal-oral), whipworms (soil), pinworms (fecal-oral), and giardia (water). It is also effective against a liver fluke that is common in the Caribbean islands.

Is a single dose of Albendazole, received once or twice a year, really helpful? Yes and no. Frequent treatment and/or easy, affordable access to clean water for drinking, cooking, and bathing would be best for eradicating parasitic infections. But in the absence of programs that can provide clean water or regular, easier, and more affordable access to medical care, a single dose once or twice a year can help to lower the parasite load in a person's body, thereby reducing the cumulative effects of the infection and improving the person's overall health. Not ideal, but better than no treatment.

It's important to point out that Esfuerzo is not a rural community. It is situated on the margins of the largest urban center in the Dominican Republic, Santo Domingo. This isn't something that affects only least-developed countries or those experiencing natural disasters. It isn't limited to quaint "native villages" where women in colorful costumes carry buckets on their heads. You don't have to be a refugee in a war-torn country to lack water. You don't have to be experiencing drought. It's an urgent need here in Santo Domingo, a large, vibrant, modern city in a lush environment. If you have regular access to waste removal and to potable water, you are in the minority in the world.

Yesterday was World Water Day 2011, and this year's theme is "Water for Cities." Some locales are celebrating World Water Week, but really, every day is water day. We can't live without it. I hope you'll think about how you use water, what lack of access to clean water might mean to you, and how the global community can work together to meet this need.

I've tried to get across a general overview of the trip to the Dominican Republic, but haven't really gotten into particulars yet. The time has come - for shoes and ships and sealing wax, or at least for talking about the specific community SOMOS serves.

As an aside - several people have asked me recently what SOMOS stands for. SOMOS is the Student Organization for Medical Outreach and Sustainability. I've linked to several resources before that pertain to the origins and development of William & Mary's outreach initiative in Paraíso; here they are again, with a few new additions, in as chronologically-appropriate an order as possible:

I described the route to Paraíso and Esfuerzo from Santo Domingo in a previous entry. Paraíso is a barrio of the city of Villa Mella, situated North of Santo Domingo. It comprises four smaller communities: Altos, 28, 6, and Esfuerzo. Via conversations with Dr. Aday, my understanding of a "community" in this sense is that in order for a group of people/homes to function as a community and be represented in the Junta de Vecinos, it takes approximately 10 people to declare themselves a community. In this case, the communities are relatively geographically distinct, especially Altos and Esfuerzo. Altos, the most economically privileged (although still very socioeconomically depressed, compared to other Villa Mella neighborhoods), occupies the highest ground and is home to a K-8 elementary school, Escuela Paraíso. This school is the center of SOMOS operations in the community; it hosts the clinic run by our medical staff and serves as a base for the research teams and housecall teams when they're not in the field.

The classrooms are a more minimalist version of those in the schools I attended in California when I was a child. The design of the school felt very familiar to me. All doors open to outdoor walkways. The windows, like most of the windows on the nicer homes in this barrio, are outfitted with shutters but no glass. During most of our time at the school, a breeze came from the North through these shutters.

The school was not in session while we were there. A friend laughed when I asked if it were "winter break." "I think here they just call it 'Christmas vacation,'" she said. Indeed, the Christian holidays are predominant here - while I believe this is a public school, the room we used for our pharmacy had an area set aside for a nativity and posters on the wall about baby Jesus.

In the room we used for registration and triage, this poster was on the wall:

The bar graph and pie chart appear to represent different issues affecting a population - perhaps the children in the school? - including violence, death, being orphaned, and broken families. I wish I knew more about how this poster came to be on the wall, and what the discussions were that surrounded it.

What is the community like beyond the school walls?

The streets in Altos are hard-packed dirt and occasional pavement, bordered by cement curbs and sidewalks. To the North, the road above descends into Paraíso 28, which I believe is named for the main street running through it. Continuing through 28, one reaches Paraíso 6. On the first day of the clinic (Monday, Jan 3), I accompanied several students as they invited residents of 28 and 6 to the clinic. The pictures in the rest of this post are from that morning.

Most of the homes in 28 and 6 are cinderblock or concrete, especially toward the top of each hill. Homes at the bottoms of hills are typically either cinderblock, wood, or patchworked tin/other materials. Most homes in these two communities and in Altos appear to have electricity and many appear to have running water. Many women were scrubbing their cement floors and patios as we walked through the neighborhoods, with liberal water use, which contributed to my assumption regarding access to running water. The floor-washing appeared to be the source of the runoff in the ditches (below left). Also note the storm drain. This particular hill is among the most developed in Paraíso 6. The blue wooden home (below right) is toward the bottom of the same hill, on the opposite side, heading toward the periphery of the sub-community.

One of the characteristics of 28 and 6 that jumped out at me was the amount of garbage on the streets and in yards. Again, altitude mattered: toward the tops of hills, there was not as much, but toward the bottoms of hills and on narrower streets and alleys, there was more accumulation of refuse, mostly in the form of food and food packaging - husks and rinds, plastic bottles and caps, water baggies, metal cans, plastic and foil wrappers, and lots of plastic bags. I also noticed metal hardware, chipped hard plastic, and a lot of broken glass. Most of this garbage appeared to be old - it was tattered and trampled into the dirt, and had become virtually part of the soil. It's surprising to me now how nonapparent this is in the photos, and it impresses further upon me how the trash has been incorporated into the soil. Toward the outskirts of each community, there are larger accumulations of newer trash, and all over the communities, especially toward their peripheries, trash is burned daily. On lower ground, the drainage ditches are full of it.

Trash collection is one of the most significant needs of the sub-community of Esfuerzo, as I will detail in a later entry, but even in sub-communities where waste removal is not as difficult as it is in Esfuerzo, trash in the environment is still an issue. During the course of the week, I came to understand that this results in a confluence of many different issues, including access to waste removal resources, concerns about disease, and cultural norms related to litter.

Later this week, I'll take us into Esfuerzo proper and elaborate on the most significant concerns of its residents.

I mentioned yesterday that I'm having trouble with the broad question, "how was it?" and its cousin, "what was it like?" Yesterday and this morning two more friends asked. So this is my what-it-was-like post. Then we'll head back into Esfuerzo and talk (literal) trash.

There is no one answer to "what was it like?" The experience is like a sandwich too big for me to figure out how to eat it. I'm still working on the angle of my bite while people are asking me what it tastes like. Or a dish made of a type of meat we don't eat here in the US, and people want to know what that meat tastes like, and I'm expected to say "it tastes like chicken," but how do you get across that it's like chicken cooked in spices for which you don't know the names?

Av Mexico & Calle Altagracia, Santo Domingo

what was it like?

It was amazing. It was incredible. It was exhausting. It was invigorating. It was draining. It was refreshing. It was mind-blowing. It was commonplace. It was nothing I expected. It was everything I expected.

what was it like?

It was nothing like the US. It was remarkably like the US.

what was it like?

I saw homes patched together from pieces of corrugated metal in which residents were watching The Fairly Oddparents on a 13" color TV. Somebody from home implied to me that their outreach trip was somehow more authentic or more necessary because the residents of the place where they went had dirt floors, while the people I was visiting had cement floors.

I saw difficulty in communication between members of the government/elevated social classes with members of marginalized communities. I saw internet cafes in or near those marginalized communities. I saw colmados with shelves loaded with expensive rum and soda and I heard about how little protein residents of Esfuerzo consume. I was reminded of the problems we face in the US with affordable access to healthy, sustainable food and other lifestyle products.

what was it like?

There was trash everywhere out of doors, while indoors, every floor of every home was scrubbed and dust-free.

what was it like?

The perfect marriage of idealism and practicality. There was a sense of being "home" among people who understand being fully-idealistic at the same time as one is fully-practical. At any time, there might be a discussion of politics or privilege or sustainability. At the same time there was a constant undercurrent of energy and excitement, of a song-and-dance number that might break out at any moment.

what was it like?

I was sick and sleep-deprived when I arrived. Lack of sleep and exposure to environmental pollution (dust, exhaust, smoke from burning trash) contributed to a painful tonsil infection and bronchitis. The most common chief complaint in the clinic is "gripe," which is basically respiratory irritation/asthma. I had gripe from a virus and brief exposure to environmental pollutants. Now try living in that 24/7 without a buddy who's an MD traveling with a pharmacy.

Before the trip I packed Lexapro for anxiety, ibuprofen for my throat. During the trip I availed myself of: neosporin and Band-Aids for a cut that got infected, acetaminophen when my ibuprofen ran out (for throat pain), Zithromax (for throat infection), loratadine (AKA Claritin, for respiratory symptoms), albuterol (for bronchitis). At home these things are also plentiful, relatively cheap, and easy for me to access.

what was it like?

It was a vacation from my family. All of my meals were prepared by somebody else, nobody interrupted my train of thought or my attempts to feed myself. Other people organized transportation, made my bed, brought fresh towels, called the shots. I needed less "me time" because there were fewer demands placed on me. I felt touch-starved because I wasn't getting enough hugs.

what was it like?

I was absolutely 100% able to do nothing but document, full-time. I was not running the show and I did not have to return from the show to run some other show, so I could just record things as they happened. Occasionally I felt badly for observing rather than doing the heavy lifting (although I also did scut work, hauled trash bags, sweated and stank), but then had to stop myself and remind myself that my work is important. As the documentarian, I provide witness and a link to the outside world. I'm a doula for social change, holding the space.

Everybody PUSH...except the photographer

what was it like?

A complete validation of some of the principles by which I live and parent. I witnessed collaborative, constructivist methods at work at the college level (between Dr. Aday and his students) and at the social level (between the SOMOS team and the residents of Esfuerzo and beyond). This renewed my dedication to inquiry-based learning and empowerment of individuals as tools to facilitate social change.

what was it like?

Frustrating. I couldn't process information quickly enough to relay it to people who wanted it in the States. I couldn't keep on top of my backlog of images. I needed more background information in order to understand the information I had, and every piece of background information only led to more questions.

what was it like?

I don't feel like I know the residents of Esfuerzo well enough to talk much about them. Like anybody anywhere, they're complex people with histories and relationships and wants and needs and good and bad character traits, only a tiny fraction of which I know about. Like anybody anywhere, some of them love to ask you in for coffee, and some are less inclined to host guests. Some have gripes about their neighbors, some are movers and shakers, some are on the social periphery. So you're not going to hear a lot of "people in Esfuerzo/Paraíso are like XYZ" from me. You can't really sum up people like that, not here, not anywhere.

what was it like?

It was inspiring to be in the presence of young adults who are exploring social issues that I wasn't even aware of until much later in my life. It was impressive to see the grasp of those concepts that they have, considering that I wasn't emotionally ready for some of those concepts until my 30s. I'm wondering what choices I can make while raising my children that will enable them to be able to engage at that level (if they so choose) when they are in college and beyond.

what was it like?

Maddening to see the breaches in security even while the US pours hundreds of millions of dollars into new technology and TSA staff. Pat-downs and full-body scans aren't making America safer. TSA agents who tell people "you aren't allowed to bring this...remember that for next time" or who are inconsistent about what they think looks fishy on the standard X-ray aren't making America safer, either.

There was razor wire surrounding the yard of the school where we held our clinic. The same school has a sign over their Kindergarten classroom proclaiming it to be a Montessori program. So close to my experience, so far from it.

aspects of Escuela Paraíso

what was it like?

I'm thrilled by the photos I took. I'm depressed by the ones I missed. I'm proud of my skills. I'm humbled by the skills others have that I still lack.

what was it like?

The air smelled like chocolate in some places and like old garbage in others. There were gorgeous sunrises and sunsets and double rainbows. There were beggars in Santo Domingo who were far more persistent than any others I have encountered. There were dogs everywhere. There was no such thing as a free lunch. There was less punctuality and more (or just different) interpersonal politics. There were beautiful 500-year-old churches and ruins that redefined my idea of "colonial" and reminded me of the explorers and conquistadors who brought slavery and genocide, the effects of which are still apparent today.

what was it like?

My kids missed me but not terribly painfully so. They were unimpressed by the ability to video-chat from one country to another. My husband and in-laws deftly kept the home fires burning. I came home to a ship-shape house and lots of snuggles. My fantastic egalitarian spouse knew I'd need some time to catch up on sleep and had also meal planned and grocery shopped for the week to aid us with re-entry. This man is fab, and I sang his praises all week. Thanks again, y'all, for making it possible for me to do this.

Welcome home "Jees" :o)

what was it like?

I'm not sure I can ever really answer that question. I hope to go back to try.

I've been back since Saturday evening and spent the rest of my weekend catching up on sleep and snuggles, then dove into a business-as-usual week with everybody heading back to school and work and all of our other usual routines. Aside from a mild panic attack in a WaWa shortly after getting off the plane, which I'm sure I'll come back to later, re-entry has been OK. Slight culture shock, nothing I can't handle. Many thanks to the experienced friends who have commiserated or advised me to stay out of Target or Kroger for a few days.

(As an aside...while I'm thinking about it: when I heard that the Carytown Kroger, which is already a really big grocery store, is expanding by a good 50% or more so that they can carry more products, my first reaction was to think, how many products do you really need? I have trouble finding stuff already! Now, though, that reaction is even more intense. Really?!? I mean, there are already at least ten brands of peanut butter, several consistencies of each, many jars of each consistency. Sometimes more than one size of each product. There's a whole aisle plus of cheese. There is a beer section, a dairy section, a coffee and tea section, a juice and water aisle, and a soda aisle - all just for drinks, not counting the Natural Foods section. Not to mention the smaller coolers of drinks here and there. What will we fill 50% more space with? More beer? More cheese? More boxes of Band-Aids with different cartoon characters on them?)

So back to the Dominican. While I was there, I was in taking-it-all-in mode for the first couple of days. After that, what I had learned led to yet more questions, and I found myself endlessly trying to step back one more level, to understand how the government is structured, or what services people in places outside Esfuerzo typically receive, or how neighborhood associations work.

Our days there were very long. We got on a bus at 7am and returned to the hotel around 6pm, after which we usually had a brief meeting, then a few moments to ourselves (I usually used this time to upload images), then dinner, then maybe another meeting, then some social time if you were still able to stand. By then it was about 11 PM. I was usually beat by that time but wanted to sort through the hundreds of images I had captured and hopefully add some captions, feeling as I did that the images shouldn't be viewed without contextual information being provided. I usually threw in the towel between 12:30AM and 1:30 AM. Then back up at 6-6:30 AM to start again. There was no catching up, no time for me to get out of doing and engage in mentally processing to a point where I could write.

Meanwhile, a couple of folks back home were asking via Facebook: what is it like? I still don't know how to answer that, but I'm going to step back a bit and slow it down, and hopefully by the end, you'll have a little bit of an idea of where we were and what we were doing.

Before leaving and during my first couple of days there, here's what I was wondering with regard to the purpose of SOMOS and life in the Dominican:

How do we define "marginalized" and "poverty"?

What is the overall standard of living in the DR? How do we decide how what is necessary and what is luxury? How does life in Paraíso compare to life on average in the DR?

Why Paraíso/Esfuerzo? How was this community chosen?

The phrases "medical outreach" and "humanitarian aid" evoke ideas in each of us about the places where outreach workers go. I was envisioning dirt floors, very improvisational shelters, no electricity, little to no access to potable water, lots of obvious illness. I had a notion - based, I'm sure, on the sum of my experiences and exposures - that an overseas effort such as this one was only worthwhile if the need was immediate and severe. This reflects the savior complex common in our culture: affluent benefactor who is model of good health and 21st century prosperity swoops to the rescue of disadvantaged, pity-worthy, third-world people and cures ills (however temporarily) via application of humanitarian Band-Aids. I may recognize the complex, be critical of it, and feel cautious about it, but that doesn't mean it doesn't still reside in me. And it does.

Please note: I'm using the words benefactor, disadvantaged, and third-world very self-consciously. They're part of the language of unchecked assumptions.

Before leaving, I looked at some data on the Dominican Republic. I wanted to know, why them? I compared DR data to US data in the CIA World Factbook. I pondered what makes something a human "right" and looked at what the UN has determined to be the rights of all people. I wondered, when do we offer assistance to people in another country? How do we assess need and how do we decide that we are the ones to meet that need?

I can't say that I've answered that yet. In discussing the roots of SOMOS during the trip and thinking about it more since then, I've realized that I'm still unclear on how the initial "duffel bag medicine" trip came into being and how Esfuerzo was chosen. What I can tell you is what I do know about Esfuerzo and about SOMOS. And I've gone around my ass to get to my elbow here, so I'll try to keep it brief.

Part I: what and where is Esfuerzo?

Esfuerzo is one of four self-defined communities in the neighborhood of Paraíso, in the city of Villa Mella, in the region of Santo Domingo Norte. Which is, as its name indicates, to the North of Santo Domingo, the capital of the Dominican Republic. I've used Google maps to cook up some visual aids (click on each to view larger):

Just to get your bearings - view of continental US, with Hispaniola/Republica Dominicana outlined in red:

The island of Hispaniola - Santo Domingo area outlined in red:

Santo Domingo area. Villa Mella outlined in red.

Villa Mella map. Paraíso portion of the city outlined in red.

Satellite view of Paraíso, with roads outlined and communities/neighborhoods labeled (Esfuerzo, Altos, 28, 6). The complex of three large rectangular buildings in Altos (lower left) is the school that hosted our clinic for the week. All of Paraíso is socioeconomically depressed when compared with the surrounding region. Esfuerzo, on the upper/mid left, is the most marginalized of these communities.

Satellite view without map overlay. A small river curves around Esfuerzo to the West and South, hidden by trees in this view. The large rectangular open area between Altos and Esfuerzo is a flood plain, la canyada. Drainage ditches run toward and alongside la canyada, but are insufficient to drain rainwater quickly, so that when it rains, the river swells and the drainage ditches back up, leaving the canyada and parts of Esfuerzo under water. Flooding of the canyada also covers the road from Altos, cutting off access to and from Esfuerzo.

The name Esfuerzo means courage, effort, or spirit. I'd be interested in learning about the way this community got its name. (Also worth noting: Paraíso means "paradise"...and David was often heard to say "another day in paradise" at the breakfast table in the morning.)

So that's a basic sketch of the "where we were" part of things. I'll continue soon with more about Paraíso, Esfuerzo, la Zona Colonial, and things in between.

It turns out that it's very difficult not to take that kind of picture. During our first day in Esfuerzo, kids all over the community, especially those of elementary school age, were incredibly excited to see us, talk to us, tell us about themselves, as us about ourselves. Our group, which has had a relationship with the residents here since 2005, held a meeting and party that evening to share their observations, invite community members to discuss their concerns/hopes/plans, and express our gratitude for their hospitality. During the party, many children noticed my camera and asked me to take their picture.

I was of two minds about these requests. As somebody who clearly enjoys photography and who spends most of her time with the same three subjects in the same settings, I'm excited to meet new people eager to be photographed. The problem for me was that I didn't really know anything about my subjects. Considering my belief that photos do not tell stories by themselves and that context (including the experiences of the viewer and the information shared by the photographer) is key, I felt awkward about taking these photos. Then again, it felt impolite to turn down these requests.

My decision: taking the pictures, when invited, is a socially appropriate act and can contribute positively to the overall relationship between the photographer and the photographed person and/or their communities. However, the act of taking the pictures felt a little bit like signing a contract in which I was agreeing to learn about the people I am photographing, either by direct inquiry or by being observant of what was happening around me.

The process of getting to know people has been both surprisingly simple and overwhelmingly difficult. Simple because many people are eager to talk to me about who they are. Difficult because there are so many people, very little time, and my Spanish is weak.

It's also difficult when a picture is made during a brief, chance meeting. This man noticed my camera and asked me to take his picture. I was traveling around Paraíso Seis (one of the four neighborhoods in Paraíso) with a team inviting residents to the clinic and the man was on his way in the opposite direction. Aside from his request and my agreement, we did not exchange any other interaction. I don't know who he is and possibly never will.

In considering the why/when of taking a photo and the use of the resulting image, I'm realizing that I will probably never fully come to a conclusion about some points (such as the issue of model releases). Nevertheless, the experiences of this week are clarifying a number of things for me and helping to shape my overall approach to travel/street/humanitarian photography. Some thoughts thus far:

I will take a picture of a person who requests it, or of a subject they suggest, when it feels socially and ethically appropriate to me.

I will take photos that document the work of a group in ways that help to illustrate the group's work, and in a manner sensitive to all of the people in the image.

I will capture other images that call to me only when they do not detract from the overall purpose for my being at a location/event.

I will never sell a photo of a person who has not signed a model release.

I will not profit from images that depict humanitarian work or the locations in which that work is being carried out.

I will make efforts to provide copies of photos, especially portraits, to people depicted in them.

When sharing pictures, I will provide as much context as I am able, in the form of personal storytelling, blog entries, captions, and links to other information.

In order to preserve this contextual piece of photo sharing, I will retain all rights to my photos on sharing sites such as flickr, so that they are not used by other groups/sites in ways that might omit the information I provide and/or disrespect the members of the community pictured.

I will grant rights of use to members of the team involved (in this case, SOMOS) for illustrative purposes when recounting their own experiences.

I will grant republishing rights to others if and only if they they are planning to use these images in a manner consistent with the principles listed here.

I will continue to provide limited reproduction rights to images nonspecific to the SOMOS effort or other humanitarian efforts but captured during those efforts (example).

It's a lot to think about, and I know it's something that I'll continue to mull over as long as I'm taking pictures. For some situations I may find satisfactory long-term positions. For others, I may constantly be revisiting them.

Flickr set of all photos from this trip processed to date is here. I'm adding information about each photo as time allows. If you would like to copy and share one or more, please contact me.

I'll leave you with this strange coincidence to chew on: I previously linked to an article about National Geographic photographer Steve McCurry's follow-up on finding "the Afghan girl" whose image was used on an NG cover in 1985. It's an iconic image. If you don't believe me, check this out:

That is a painting that I noticed on the wall of La Cafetera, a hole-in-the-wall sandwich shop down the street from my hotel here in Santo Domingo. It is, as you have probably noticed, based on McCurry's famous portrait of Sharbat Gula. McCurry's original image did not include shifting desert sands and Dali-inspired Greek temple ruins, nor was Gula's scarf originally held up by Raphaelesque cherubs. Considering that she felt angered by McCurry's intrusion the first time he photographed her, I wonder what she would think about this reinvented portrait or about its place on the wall of an eatery almost 8,000 miles from her home?